Monday, August 31, 2009

I would like to challenge everyone to start using correct terminology when it comes to the intact boy, intact man, and intact penis.

If you must qualify them based on their genitalia, they are INTACT.

Not 'uncircumcised'.

It is troubling to hear (read) people use the word 'uncircumcised'.

We do not call women 'unclitoridectomised' or 'unlabiaplastectomised'. Girls who have not been subject to the hand of a mutilation knife are intact. And so are boys. They come from within fully formed and perfect ~ all in one piece and made just the way they are meant to be made ~ Intact.

In their most excellent book, What Your Doctor May Not Tell You About Circumcision, Drs. Fleiss and Hodges encourage us to call our babies brought home whole exactly what they are - INTACT. "'Uncircumcised'," they write, "is an unscientific, unhelpful, useless, and confusing term because it uses terminology normally reserved for abnormality to name a natural, normal body part. Let us avoid confusion and stick to science." Yes, let's!

Embarrassingly, I, too, was once guilty of throwing around the term 'uncircumcised'. In fact, when writing my dissertation I used the word before being as informed as I (thankfully) am today on intactivist issues. I cringe when reading over my early publications and know that libraries house a document I wrote, but made such a grave mistake of genital integrity awareness within. I suppose it is reflective of the slightly ignorant time in which I wrote it. And thankfully times are changing!

So when you are talking about your intact son...or your intact husband...or how you plan to keep your baby boys intact - do just that! You don't need to say, "I am against circumcision" but rather, "I believe in keeping all babies intact at birth." If you work in obstetrics, midwifery, or L&D, you can ask, "Would you like to keep your baby intact?" rather than [oh, how I hate this question] "Would you like your baby circumcised?"

Words have meaning. They influence our thinking about the concepts they surround. Just as the intact clitoris is the normal, natural clitoris--the intact penis is the normal, natural penis. We must normalize and naturalize the word 'intact' in the United States.

Many Jewish parents today are electing to have a Brit Shalom in place of a brit milah [circumcision ceremony]. For more information, and to talk with other Jewish parents electing this for their sons, see:

In the land before children, my husband and I had many a circumcision debate over dinner and drinks with friends. I always humored him as he made the comparison between circumcision and female genital mutilation, secretly knowing that I would trump his concerns with my Judaism card. He had agreed to a Jewish wedding and a Jewish household, and well, Jews circumcised their boys. End of story.

I'm not the most religious Jew ever, and my friends and husband have often wondered how I can even call myself a Jew. (Obviously they are not Jewish!) I can only say that being Jewish is just something I am, whether I attend synagogue on a regular basis or remember Shabbat or eat BBQ or whatever. I am a Jew. And there are certain things that even a reform Jew holds dear and circumcision is one of them. It symbolizes our covenant with G-d. It is what has identified us, at least those of us with penises, throughout the centuries. Circumcision is not something that a "good" Jew questions. It is a given.

Once I actually became pregnant, I assumed I was having a girl. I, like many Jewish mothers before me, wanted a girl in part because I didn't want to deal with the circumcision issue. Debating it over drinks and actually doing it are two completely different things. As my belly grew, so did my suspicion that I was having a boy. (Of course we could have found out for sure, but again I humored my husband's wish not to know until the birth.) Around 30 weeks into my pregnancy, I decided I better deal with the circumcision issue. All discussions with my husband ended in a stalemate. I decided to schedule a meeting with a rabbi so we could gang up on him.

The rabbi who married us had since retired, so I had my choice of three other rabbis: A forty-ish up-and-comer with three girls in their tweens, a female in her thirties with a one-year-old son, and a new guy I didn't know much about. I went with the female, Rabbi Cohen. I figured she could speak from personal experience and that the issues would be fresh in her mind.

Between the time I made the appointment with the rabbi and the time we were actually scheduled to go, I got an email from my friend who is a practicing midwife in California begging me to reconsider my decision. I don't know if she witnessed a recent circumcision or what, but she was adamant. I went through the Jewish rigmarole with her and she responded with a link to Nocirc.org and specifically said to look at the information on Judaism and circumcision.

What I found shocked me. There were stories of Jews from all over the United States who had decided not to circumcise their children. Not only were they talking about it, they were making it seem ok. And most importantly, they were still accepted in the Jewish community. I couldn't believe it. For the first time, I let myself really consider not circumcising my son. I also let myself read the circumcision boards at Mothering.com (which are decidedly anti-circumcision). I even found a few Jewish moms there who had kept their sons intact. I did a lot of soul searching and a lot of typing.

When you take the religion out of circumcision, and really look at what the procedure actually involves, it is easy to see why more and more people are choosing to leave their sons intact. I thank my lucky stars for the Internet and the information it provided me on circumcision (as well as a million other mommy related questions). The Internet has allowed me to question the status quo; to find out why things are they way they are. A privilege our foremothers did not have. For me, the mere thought of giving birth to my precious baby at home without any medical intervention and then cutting off a part of his body eight days later just seemed absurd. I told myself that if G-d created my son with a foreskin, then he was going to keep it.

I am a 72 year old retired physician, a Jew who is an active member of a Conservative synagogue, and a grandfather.

When I was in Medical School in the 1950s, almost all newborn males were circumcised. Despite the fact that prophylactic surgery was not generally performed, we were taught that circumcision was the correct and healthy thing to do. It was thought to control masturbation, decrease cancer risk, and help curtail sexually transmitted diseases. We learned nothing of foreskin anatomy and function. Infant nervous systems were thought to be undeveloped and their pain was so trivialized that it was almost ignored. As a young physician, I participated in many circumcisions. Over the years I’ve witnessed brit milah in the homes of friends and family. I was mildly uncomfortable with the practice, but like most physicians, and like most Jews, I said and did nothing to question circumcision.

Three years ago, as I was about to become a grandfather for the first time, my interest in the subject became more focused. I learned that more and more physicians now realize that any potential benefits of circumcision are far outweighed by its risks and drawbacks. The American Academy of Pediatrics has stated that “Routine circumcision is not necessary”. Whether done by a physician in the hospital, or a mohel in a ritual brit milah, the procedure has significant complication rates of infection, hemorrhage and even death. Mortality may actually be higher than thought since some of these deaths have not been attributed to circumcision, but listed only under their secondary causes, such as hemorrhage or infection. I’ve learned of the very important role the foreskin has in the protection of the head of the penis in the infant, and in sexual functioning in adulthood. It has also been shown that the newborn feels pain even more acutely than adults do, and that many of the infants who stop crying during circumcision are actually in a state of traumatic shock. To my amazement I learned that the USA is now the only country in the world routinely circumcising babies for non-religious reasons.

With these overwhelming reasons not to circumcise, I began to look at the practice of ritual circumcision in the Jewish community and I learned that: circumcision is not an identity issue. You do not need to be circumcised to be Jewish any more than the need to observe many other Jewish laws. The bottom line is this: if your mother is Jewish, you are Jewish, period. And in the Reform tradition, patrilineal descent is also accepted. Among Jews in Europe (only 40% of newborn Jewish boys in Sweden are being circumcised), South America, and even in Israel, circumcision is not universal. Growing numbers of American Jews are now leaving their sons intact as they view circumcision as a part of Jewish law that they can no longer accept. Alternative brit b’li milah or brit shalom ceremonies (ritual naming ceremony without cutting) are being performed by some rabbis. Increasing numbers of intact boys are going to religious school, having bar mitzvahs, and taking their place as young adults in the Jewish community.

As a Jewish grandfather, I want to assure young couples about to bring a child into the world, that there are other members of the Jewish “older” generation, including other Jewish physicians, and even some rabbis, who feel as I do. If your heart and instincts tell you to leave your son intact, listen!

ScienceDaily (2009) — Variations in both human milk feeding and in the weaning diet are linked to differences in growth and development, and they have independent influences on body composition in early childhood, according to a new study.

Previous studies suggest that the early environment may be a significant factor in childhood obesity. This study used dual x-ray absorptiometry to make direct measures of body composition in children at four years of age whose diets had been assessed when they were infants. The findings showed that children who had been breastfed longer had a lower fat mass which could not be explained by differences in family background or the child's height.

"Most studies linking infant feeding to later body composition focus on differences in human milk feeding, but our study also considered the influence of the weaning diet," said Dr. Siân Robinson, PhD, of the MRC Epidemiology Resource Centre, University of Southampton in the United Kingdom and lead author of the study. "We found that, independent of the duration of breastfeeding, children with higher quality weaning diets including fruits, vegetables, and home-prepared foods had a greater lean mass at four years of age."

In this study, researchers assessed the diets of 536 children at six and 12 months of age. Diet was assessed using a food frequency questionnaire that was administered by trained research nurses to record the average frequency of consumption of specific foods. The age at which solid foods were introduced into the infant's diet was also recorded. In this study 'weaning' is defined as the period of transition in infancy between a diet based on milk feeding to one based on solid foods. The subjects' body composition was assessed at four years by dual X-ray absorptiometry.

"These findings are enlightening," said Professor Cyrus Cooper, Director of the MRC Epidemiology Resource Centre. "An influence of qualitative differences in the weaning diet on childhood body composition had not been described before."

Sunday, August 30, 2009

My daughter, River, is having a hard time sleeping. Apparently, the pain of those new molars chewing their way toward the light is somewhat agonizing. Who knew? My own teeth have been around so long they're about ready to move on - only through constant applications of toothpaste and floss have I managed to convince them to stick around for one more pot roast. Really, though, most of the time I take my pointy little friends for granted.

River does not. I'm impressed that she holds it together as well as she does, greeting each day with a delight and a frank curiosity that continue to charm those of us for whom eating dirt has long since lost its allure. She's the funniest person I know, and possibly the smartest, having learned all the different parts of the face, all the zoo animals and their sounds, and how to communicate in sign language despite having such tiny arms. All of this, and more, she accomplishes without benefit of tequila or opium, regardless of the pain in her jaw. Her only narcotic is regular applications of mook (milk) from someone whose name is, I think, Mook, but who also looks like my wife, Erin.

Admittedly, the mook is pretty important. As chief enabler, Erin continues to indulge River's now 18-month craving, and has no intention of stopping, a dedication that inspires admiration in some, abject horror in others. Being one of those modern, "involved" dads, I make dinner, clean the kitchen, and try to help out as best I can, though I often find myself removed to the periphery of River's universe due simply to the harsh reality of my inadequate, non-mook-bearing man-teats.

Nighttime, in particular, is when River seems to need me least - asleep, I have even less to offer than usual. When bedtime arrives, when the toys are put away, the books read, the lights turned out - that is when the molars return to torment my daughter, and when she most needs my wife, her mother.

Which is why I was so surprised when, recently, after her bedtime mooking failed to lull her to sleep, River began asking for me.

"River's waiting for you," Erin called to me one night, somewhat bemused. "She's asking for her daddy."

This is a curious turn of events, I thought. I entered our bedroom, where River was sitting up in our bed.

"Daddy!" she said. "Hep!" (Help!) She held out her arms to me. Indulgently, I held her.

"Ooh-ooh! Ah-ah!" she said, making the sound of her favorite sleepy-time monkey. I procured the creature.

"Up! Up!"

I stood.

Then, wonder of wonders, she put her head on my shoulder and, with one arm around her monkey and the other around my neck, drifted off to sleep.

This, as it turns out, was to be our routine for an entire blessed month, an era that became known as The Time of Daddy-Hep. Or, from my wife's perspective, The Time of Mommy-Sleep. I took my duty seriously and did not complain, even when River would wake me after her 4 a.m. mooking with loving smacks to the face, to demand, "Daddy, hep!"

"I'm sorry," Erin would apologize, sounding concerned. "I know you have to get up early."

"It's OK," I'd sigh long-sufferingly. "River needs her daddy."

And I'd pace to and fro, singing a lullaby, patting River gently on the back while she gently and amusingly patted mine, all the while suppressing tears of gratitude, which threatened to betray my true feelings about this wondrous new hardship.

It can be difficult being a modern father - one of those elusive, poorly drawn characters of whose role in contemporary family life no one is ever quite sure. What is sure is that the old ways no longer serve; even if I had the time to recite the patent homilies of Father Knows Best, I'm not sure I'd have the stomach.

We make our ways in the fashions that seem best to us, each man forging a brave new definition of father out of bits of the past and pieces of the present. Just as the modern woman has made inroads into fields that were once the exclusive provinces of men, so has the modern man made advances of his own. Every time we hold our child, change a diaper, or wipe a runny nose, we realize our own power to nurture - while losing none of our "manliness" in the process.

Even so, in spite of it all, I can't deny the nagging feeling that I am not and never shall be a true "mother" - and, perhaps most shocking, don't want to be. It's not that I don't want to be needed. I want that more than anything. No, it's more that I recognize that there are limits to how much the line dividing gender roles can be smudged or erased - limits that are, for most, a practical necessity.

Defining exactly where that line is seems to be a kind of obsession with everyone these days, from the hellfire camps of the fundamentalists (clearly defined gender roles, and a pox on all ye who stray), to the we're-all-the-same notions of certain cultural postmodernists (limits? what limits?). In reality, it seems to me that The Line is a chimera, its shape and solidity up to each individual to define: What is true for you may not be true for me, and vice versa. Taking a hard line regarding The Line only makes it harder to perceive where it lies.

So my advice to all the other modern fathers out there who are searching for their just and rightful place in the modern family paradigm is this: Do not fear for the loss of your manliness. If "manliness" is a quality that could truly be lost, then you truly didn't want it in the first place. Better to strip away - gently, gently - all that is not real, all that is not true, and find the true core of manhood, which is perhaps far more nurturing and far less "manly" (by traditional definitions) than we might ever have imagined.

But I digress. As I was saying, all things evolve; change is the only constant. (I was saying that, if only to myself.) All too soon, the brief period of my daughter's need for me was over. One night I came to the bedroom, a spring in my step and a tune to hum, when I noticed that something was different. River was regarding me with something like suspicion; as I got closer, it only grew worse.

"Mommy!" she said.

I frowned. "No, Daddy!" I countered. She wasn't buying it. I picked her up.

She struggled. "Mommy!" she cried, a tone of panic creeping into her voice.

"But I've got your monkey," I offered plaintively.

I was thrown off my game. I tried all the usual stuff - patting, singing, pacing - to absolutely no avail. It was over. In seconds, my sweet, precious baby girl became a shrieking tangle of straining limbs, a crescendo of panicked cries of "Mommy!" issuing from her rather impressive vocal cords.

"ls there a snake on my head?" I asked Erin.

But no - at that point, a snake on my head would have probably been a positive development, something for River to focus on to take her mind off the hideous monster that was apparently trying to kidnap her and take her away from her mommy, perhaps for ever and ever.

The monster acquiesced. I returned River to her mommy.

I blame River's molars. In retrospect, I should have seen it coming. Although Erin had told me of their impending arrival, I just hadn't anticipated the impact. But you try shoving a knobby piece of bone through your inflamed gum and see how it feels. You, too, would probably cry for your mommy. I doubt you'd even think of your daddy, unless he was standing in front of your mommy - and even then, you'd be thinking of him only as a potential threat to your immediate goal of getting to your mommy and her mook.

So I don't get too wrought up about it. I know there will be times in the future when River will need her Daddy, too. Those times are made all the more precious because they are rare.

Paul Koenig is a freelance writer, musician, and artist currently residing in Arizona, with his wife, Erin, and their daughter, River.

Saturday, August 29, 2009

By Hygeia Halfmoon
Author of Primal Mothering in a Modern World, among other books
Read more from Halfmoon and check out her Cozy Cradle Baby Sling at her site here.
Posted with permission 2/09
I'm here to defend men in their right to be whole, and I don't want to hear any religious doctrine that blesses such a barbaric act. We must tackle ourselves where we least want to look - into our views about religion and how we are literally shackled to the past and to the rules which continue to be played out from one generation to the next. My dear Jewish friend, Laura Kaplan Shanley, author of Unassisted Childbirth, has something important to say on this subject:

I am so offended by circumcision that it is difficult for me to even write about it. On any given day thousands of men will meet in support groups to vent their anger over having been circumcised without a choice in the matter. Over one third of the active members of the anti-circumcision movement are Jewish. On any given day at least one hundred routine infant circumcisions will result in complications, irreversible surgical trauma, penile loss or even death. I have no problem with Jews circumcising their own as long as the 'circumcisee' is a consenting adult. A week old infant is not a consenting adult. Religious freedom is not about inflicting your beliefs on others, regardless of whether or not the other is your child. Children grow up to be adults, and many, many Jewish men are angry that they were circumcised in the name of religion.

For those who say a Jewish circumcision is more humane because the child is held by loved ones and given wine to drink, Jody McLaughlin who is the editor/publisher of Compleat Mother Magazine replies,

"Are you telling me that it is more humane to be hurt in the presence of those who supposedly love and care about you? Are you saying that it is more humane if a child's first sexual experience involving another human being is associated with blood, pain, and alcohol?"

As shocking as it may be to our western minds, little girls in other societies are routinely forced into a different form of circumcision - female clitorectomies. While the western world is condoning male circumcision with the excuse of cleanliness, other cultures are cutting out the clitoris of each and every young girl, assuring death to the power of female sexual pleasure. I am eternally grateful to organizations such as NOCIRC who work to save infants and children from the pain, torture, and destruction of genital mutilation. We need to stop the horror of sexual mutilation wherever it occurs on our planet.

It seems only fitting that we should next touch on the subject of sexuality. One aspect of the anger that is addressed in support groups comprised of circumcised men is sexual sensitivity. Their non-circumcised counterparts are enjoying a level of sexual pleasure unknown to victims of the knife.

The foreskin acts as both lubricant and masseuse during intercourse, creating a highly stimulating sensation. As a mother, I can attest to this difference between circumcised and non-circumcised males because my three-year-old intact son absolutely loves pulling and stretching his foreskin, a gleeful pride in his eyes and a smile on his face. I don't see this self-nurturing behavior in the lives of toddler victims of circumcision.

Circumcision is a primal wound that changes the course of a life. This crime, together with denial of the breast and separate sleeping quarters, defines the initial sexual experience for a huge percentage of our society's population. Pornography is that party called together: the walking wounded who, addicted to eagle-spread models in magazines search out the womb where everything was once just fine; the walking wounded who, starved of the sweet warmth of a mother's breast stare dreamily at the sight of cleavage; the walking wounded who, frustrated at their inability to know intimacy have sex with strangers who will only do it for pay; the walking wounded who, angry and anxious for the hatred they feel, rape and kill women and children.

Morris L. Sorrells M.D. discusses the penile sensitivity studies he and other doctors conducted that studied circumcised and intact penises. They concluded that circumcision ablates the most sensitive parts of the penis.

Friday, August 28, 2009

Most of us are now familiar with the International Breastfeeding Symbol. But do you know where it originated? Who was the designer of this symbol? The answer may surprise you! Continue reading for Mothering's interview with breastfeeding-advocate and stay-at-home-dad, Matt Daigle. If you have seen this symbol used in your neighborhood, we'd love to know ~ drop a note or send a picture of the symbol in use.

I was going to post another picture of the infamous "RestFull" as that is what this post is partially about, but why give Enfamil anymore photo ops than they deserve?Instead, here is a bottle (Born Free's Vented Glass Bottle) full of Human Milk donated for a Human Baby.

I recently posted a brief blurb on Enfamil's new "RestFull" formula ~ designed and marketed to "keep babies full" and "help them sleep longer." The vast majority of responses I have received have been from other concerned parents and those dumbstruck at this marketing tactic - not to mention slightly afraid at what we are going to see uninformed parents do with this 'thick' formula that 'expands' in babies' bellies.

I have also received a couple (2 to be exact) responses from people who state there is no possible way that a link can exist between formula, sleep/night-waking, and SIDS, and that such statements are outlandish. However, ample amounts of research conducted the world-over, for several decades now, show time and again that not only is there a link between these factors, there is also strong causality that exists. And so, I will re-hash a couple items here and provide sources for those wishing to dig a little deeper into the data we have.

For starters...

Babies who wake more frequently, and sleep lightly (i.e. are easily woken - or what some people call 'bad sleepers') are at a significantly lower risk for SIDS.

Babies who wake less frequently, and sleep more deeply (sometimes called 'good sleepers') are at a significantly higher risk for SIDS.

This is one reason that a formula which artificially 'fills' the stomach with chemicals and grains and goop, designed to expand internally and trick a baby's brain into thinking s/he is full, induces deeper/longer sleep, and in turn, may lead to an observable increase in SIDS cases.

In addition, the brain is on full throttle of development during the night-time hours. It is during the night that stress hormones such as cortisol decrease (unless a baby is left to cry or feels abandoned/alone) and growth hormones increase. This continues throughout adult life as well, which is the reason muscle is built and repairs faster during night time hours. However, in baby-hood, these hormones dramatically impact baby's brain development and organ growth. Because of this, babies are designed to wake easily to get necessary, frequent, high-quality nutrients all night long (via mother's milk). It literally feeds their brain. Stuff a baby up with 'empty' calories -- or a formula concoction that is designed to keep a baby full but not provide frequent, rich, quality, all-night nutrients, and you impact brain development and organ growth.

Lower neuro firing and neuro connections (which occur when a baby lacks essential nutrients during night time hours) puts babies into more of a comatose type state of mind. Some might interpret this as an 'easy baby' - one who is a 'good sleeper' - however, once again, we see an increase in SIDS as a result of the decrease in neurological activity.

Related to brain activity, sleep, and wakefulness are the components of breastmilk vs. formula. This involves glycobiology, which is a topic large enough for a site all its own. Essentially, glyconutrients are the components of the body's cells which are responsible for effective communication, healing, repair and re-building between and within all cells. Without them, cells break down, organs do not form just right, the brain (and lungs and heart and kidneys and stomach...) do not function at their normal capacity. Regulatory functions (such as respiratory and cardiovascular systems) get off kilter when glyconutrients are not present in necessary number - leading in turn to an excess of SIDS.

Breastmilk, however, is PACKED FULL of glyconutrients -- it literally is liquid gold. Nature has the perfect plan for the protection of tiny growing babies. Healing and health components are provided in an incredible high quantity with every ounce of breastmilk that is consumed. While there are multi-millions of dollars to be made if a pharmaceutical company can replicate glyconutrients artificially (they also enable the body to heal cancer cells) so far no one has been able to do so. Formula is entirely void of any glyconutrients.

All of these SIDS causes are especially true for babies born premature, or those who were induced to birth or electively c-sectioned, rather than triggering labor in their own time (when lungs are fully 'done' and baby's hormones interact with mothers to kick birth into gear). Babies who trigger labor on their own, experience the protective hormones that flood an infant's brain during labor/birth and these in turn increase baby's suckling response and his attachment/awareness through natural oxytocin release ~ another protective feature against SIDS. Unfortunately, artificial induction, elective c-section, and premature birth (along with formula feeding) is ubiquitous across the United States today. These are major components in the reasons we have the highest rates of infant morbidity and mortality in the entire developed Western world.

Many reliable studies show that formula fed babies have double to triple the risk of SIDS due to the above mentioned factors. Formula was designed to be a mere survival tool for babies who absolutely could not get the human milk they need from any other source. Formula may keep babies alive more often, and for longer durations, than feeding straight non-human animal milk (although this is also debated because of the artificial ingredients in formula). However, any form of artificial feeding is severely lacking in what babies need to grow normally and maintain their baseline health. The new "RestFull" formula only promises to intensify all of these factors, and in turn, lead to a higher rate of SIDS.

*Share-sleep (have baby sleep within an arm's reach of his/her non-smoking mother). If you are unable to breastfeed, make every attempt to access human donor milk for your baby. If you absolutely must artificially feed, have baby within an arm's reach of his/her non-smoking mother to sleep and wake to feed baby throughout the night, but do not bedshare unless you are breastfeeding. Nursing mothers and their babies are in tune with each others' bodies and natural sleep/wake cycles in a manner that non-nursing babies/mothers are physiologically not. This impacts the safety of bedsharing for non-nursing mother/baby couples. [Note: Bedsharing and sleep sharing - i.e. cosleeping/sleeping within an arm's reach of baby - are not the same thing. Sleep sharing is always beneficial for baby (no matter his source of nourishment) unless a parent smokes.]

*Keep a fan on (but not directed at baby) in your sleeping room. There is new research that shows this soothing background noise decreases SIDS risk. It helps baby stay calm during night time hours - decreasing cortisol and other stress hormones. Baby (and you!) are less likely to startle (flight and flight response to stress) when small noises occur in the night - a fan helps to drown them out.

Babies simply require night-time parenting for their normal health, wellbeing, and development. This consists of parents losing out on full nights worth of sleep. Sometimes for many months (or years!) on end. It is a part of being the caring, in-tune, gentle parent of a rapidly growing infant. If these things do not sound appealing to you...don't have a baby.

To begin a further investigation on the relationship between SIDS, formula, sleep, and night-waking see:

Aimin Chen and Walter J. Rogan. 2004. Breastfeeding and the Risk of Postneonatal Death in the United States. Pediatrics, 113: e435-e439.

Question: My general practitioner, bless his heart, is trying to convince me that sleeping with my five-month-old son is dangerous and increases the risk of SIDS. Although I have no intention of changing our sleeping arrangement, I would like to have some references to give him the next time we meet. His reference comes from what he claims to be the most recent study, which, apparently, was sent to physicians by the surgeon general. I'm in Canada, which may or may not be relevant as I'm not sure where the study took place.

Answer: It's confusing when a new mom gets all kinds of information from different sources. It's somewhat of a parenting hazard. I'm going to disagree with your GP in that bed-sharing doesn't increase the risk of SIDS. In fact, studies have shown that bed-sharing helps to regulate babies' breathing cycle because they pick up and imitate their mothers' breathing cycle. The tragic incidence of SIDS can happen anywhere and anytime—not just while cosleeping. There is still no known cause, although some risk factors have been identified. Perhaps your GP is more concerned about suffocation, which is different from SIDS but indistinguishable in an autopsy. There have been many studies recently in Canada about suffocation from bed-sharers but not much news has focussed on the proportion of babies that have suffocated in cribs. I urge you to look at the logistics of the studies you come across. How many babies were studied? What proportion was in a crib versus bed-sharing? What kinds of surfaces were involved in the cosleeping environment? What were the circumstances of the parent's health at the time of death? Who sponsored the study? Many factors contribute to suffocation and there are many ways to reduce the risk. I have an article called "Co-sleeping" at the Attachment Parenting Canada website (www.attachmentparenting.ca) that lists risk factors and how to make cosleeping safer. Dr. James McKenna is a leading researcher in the field of bed-sharing and has quite a few studies quoted on the Mother-Baby Behavioral Sleep Laboratory at University of Notre Dame website: http://www.nd.edu/~jmckenn1/lab/media.html The more important point here is that no professional should tell you what to do. All they can do is give you information and their recommendations and leave the decision-making up to you. You know your situation and risk factors the best and are in the best position to decide what is right for you, your baby, and your family.

Should I be concerned about not having enough breastmilk to nourish my baby?

Many mothers are concerned about not having enough milk. Yet the likelihood that a woman will be physically unable to produce sufficient milk for her nursling is actually low. So why is this such a common concern? Part of the answer lies in our loss of the art of breastfeeding. Many mothers have grown up in families where they are the first women in generations to breastfeed. These mothers are pioneers, doing the best they can with the information and support available to them. Unfortunately, because they are breastfeeding in a formula-feeding culture, the information they receive may be inaccurate and the support they have may be inadequate-which can undermine their efforts to breastfeed. In addition, exposure to formula advertising and being given free formula in the hospital after birth can decrease the confidence of mothers in their ability to breastfeed.

Milk supply is dynamic. It follows the law of supply and demand. The more frequently and effectively a nursling breastfeeds, the more milk the mother's breasts make. That's why recommendations to rigidly schedule and limit feedings or to never breastfeed at night (instead of responding to a nursling's cues for frequent, flexible feedings) can result in a reduced milk supply. It's also why nursing more frequently and ensuring that a nursling is effectively draining the breast are good first steps toward increasing milk supply.

Sometimes the misinterpretation of a nursling's behavior can lead mothers to think they don't have enough milk even though they actually do. Let's say a baby seems fussy after a feeding. The mother-or someone around her-may interpret the baby's behavior to mean that the mother doesn't have enough milk. A mother can have plenty of milk, but if she is engorged, the baby isn't positioned and latched on well, or the baby is using an incorrect suckling pattern because of exposure to artificial nipples, then the baby may not nurse effectively. (Such problems have solutions: they do not have to result in low milk supply or weight loss in a baby.) Or perhaps the mother has plenty of milk and the fussy baby is nursing effectively, but has thrush (an oral yeast infection) or is teething or needs to have a bowel movement. Fussiness can even be due to an ample milk supply that flows so quickly the baby has difficulty managing its abundance! These are just a few of the many reasons a baby might be fussy at the breast and that might lead to someone suggesting that a mother supplement with formula. Regardless of what leads to supplementation with formula, it is a very effective way of decreasing a mother's milk supply if her breasts are emptied less frequently and thoroughly because of it. Remember: milk supply follows the law of supply and demand.

Before or after the birth of a baby, International Board Certified Lactation Consultants and La Leche League Leaders can help mothers sort through breastfeeding advice to identify what is helpful and what might get in the way of building and maintaining a good milk supply. They can help mothers learn about positioning and latch-on so that nurslings can effectively obtain milk, how to tell a nursling is getting enough milk, and how to increase milk supply, if needed. They can also refer mothers to healthcare providers to evaluate a nursling's weight gain and development or to determine if there are any physiological causes of low milk supply in mother (e.g., a hormonal imbalance, retained placenta, previous breast surgery) or nursling (e.g., tongue-tie, low muscle tone, respiratory problems)-many of which are treatable.

Wednesday, August 26, 2009

Increasing numbers of American parents today are protecting their sons from routine circumcision at birth, but as their boys grow up, they often find themselves at odds with doctors who cling to old-fashioned opinions and hospital routines.

I often receive calls from distraught parents who say that a doctor insists that their little boy needs to be circumcised because there is something wrong. When they bring their son into my office, I almost always find that there's nothing wrong with the child's penis. Occasionally there's a slight infection, but that can be quickly cleared up with an antibiotic cream. In all my years of practice, I've never had a patient who had to be circumcised for medical reasons.

When a doctor advises that your son be circumcised, it's usually because he or she is unfamiliar with the intact penis, misinformed about the true indications for surgical amputation of the foreskin, unaware of the functions of the foreskin, and uncomfortable with the movement away from routine circumcision.

Doctors can be psychologically challenged by the sight of an intact boy. They may see problems with the penis that do not really exist. They may try to convince you that the natural penis is somehow difficult to care for. They may cite "studies" and "statistics" that appear to support circumcision.

Probably, the only problem you will encounter with the foreskin of your intact boy is that someone will think that he has a problem. The foreskin is a perfectly normal part of the human body, and it has very definite purposes, as do all body parts, even if we do not readily recognize them. There's no need to worry about your son's intact penis.

What to Say When the Doctor Says to Cut

Below is a list of some of the things that doctors have said to parents in an attempt to convince them to agree to circumcision. After each incorrect statement, I've given the medical facts to help you understand what your doctor may not know about the intact penis and its care, and what you need to know to protect your child from unnecessary penile surgery. If you ever find yourself in a situation where a doctor suggests that your child should be circumcised, the best thing that you can say is simply: "Leave it alone."

-Your son's foreskin should be cut off in order to facilitate hygiene.

My experience as a pediatrician has convinced me that circumcision makes the penis dirtier, a fact that was confirmed by a study recently published in the British Journal of Urology.1 For at least a week after circumcision, the baby is left with a large open wound that is in almost constant contact with urine and feces--hardly a hygienic advantage. Additionally, throughout life the circumcised penis is open and exposed to dirt and contaminants of all kinds. The wrinkles and folds that often form around the circumcision scar frequently harbor dirt and germs.

Thanks to the foreskin, the intact penis is protected from dirt and contamination. While this important protective function is extremely useful while the baby is in diapers, the foreskin provides protection to the glans and urinary opening for a lifetime. At all ages, the foreskin keeps the glans safe, soft, and clean.

Throughout childhood, there is no need to wash underneath the foreskin. Mothers used to be advised to retract the foreskin and wash beneath it every day. This was very bad advice indeed. When the foreskin becomes fully retractable, usually by the end of puberty, your son can retract it and rinse his glans with warm water while he is in the shower.

-Your son's foreskin is too tight. It doesn't retract. He needs to be circumcised.

The tightness of the foreskin is a safety mechanism that protects the glans and urethra from direct exposure to contaminants and germs. The tight foreskin also keeps the boy's glans warm, clean, and moist, and when he is an adult, it will give him pleasure. As long as your son can urinate, he is perfectly normal. There is no age by which a child's foreskin must be retractable. Do not let your doctor or anyone try to retract your child's foreskin. Optimal hygiene of the penis demands that the foreskin of infants and children be left alone. Premature retraction rips the skin of the penis open and causes your child extreme pain. There is no legitimate medical justification for retraction. The child's discomfort is proof of that.

-Your son's foreskin is "adhered" to the glans. It must be amputated.

The attachment of the foreskin and glans is nature's way of protecting the undeveloped glans from premature exposure. Detachment is a normal physiological process that can take up to two decades to complete. By the end of puberty, the foreskin will have detached from the glans because hormones that are produced in great quantities at puberty help with the process. There is no age by which a child's foreskin must be fully separated from the glans.

Some misguided doctors might suggest that the "adhesions" between the foreskin and glans should be broken so that your son can retract his foreskin. This procedure is called synechotomy. To perform it, the doctor pushes a blunt metal probe under the foreskin and forcibly rips it from the glans. It's as painful and traumatic as having a metal probe stuck under your fingernail to pull if off. It will also cause bleeding and may result in infection and scarring of the inner lining of the foreskin and the glans. The wounds that are created by this forced separation can fuse together, causing true adhesions. There is no medical justification for this procedure because the foreskin is not supposed to be separated from the glans in childhood. If any doctor suggests this procedure for your son, firmly refuse, stating, "Leave it alone!"

-Your son's foreskin is getting tighter. It no longer retracts. Something is wrong. He will have to be circumcised.

Sometimes, in childhood, a previously retractable foreskin will become resistant to retraction for reasons that are unrelated to impending puberty. In these cases, the opening of the foreskin may look chapped and sting when your son urinates. This is not an indication for surgery any more than chapped lips. This is just the foreskin doing its job. If the foreskin were not there, the glans and urinary opening would be chapped instead. Chapping is most often caused by ov erly chlorinated swimming pools, harsh soap, bubble baths, or a diet that is too high in sugar, all of which destroy the natural balance of skin bacteria and should be avoided if chapping occurs. The foreskin becomes resistant to retraction until a natural and healthy bacterial balance is reestablished.

You can aid healing by having your son apply a little barrier cream or some ointment to the opening of the foreskin. Acidophilus culture (which can be purchased from a health food store) can be taken internally and also applied to the foreskin several times a day to assist healing, and should be given any time a child is taking antibiotics.

-Your son's foreskin is red, inflamed, itching, and uncomfortable. It has an infection and needs to be cut off.

Sometimes the tip of the foreskin does become reddened. During the diaper-wearing years, this is usually ammoniacal dermatitis, commonly known as diaper rash. When normal skin bacteria and feces react with urine, they produce ammonia, which burns the skin and causes inflammation and discomfort. If the foreskin were amputated, the inflammation would be on the glans itself and could enter the urethra. When the foreskin becomes reddened, it is doing its job of protecting the glans and urinary meatus.

Circumcision will have no effect on diaper rash. Change your baby's diapers more frequently and use a barrier cream until the rash clears. Harsh bath soaps can also cause inflammation of the foreskin. Use only the gentlest and purest of soap on your child's tender skin. Resist the temptation to give your child bubble baths, because these are harmful to the skin. Never use soap to wash the inner foreskin because it is mucous membrane, just like the inner lining of the eyelid.

Foreskin infections are extremely rare, but if they occur, one of the many simple treatment options is antibiotic ointment along with bacterial replacement therapy (Acidophilus culture). We don't amputate body parts because of an infection. Most infections of the foreskin are actually caused by washing the foreskin with soap. Leave the foreskin alone, remembering that it doesn't need any special washing, and infections will be unlikely to occur.

-Your son is always pulling on his foreskin. He should be circumcised.

I can assure you that, whether circumcised or not, all little boys touch and pull on their penis. It is perfectly normal. Intact boys pull on the foreskin because it is there to pull on. Circumcised boys pull on the glans because that is all they have to pull on. Little boys sometimes will adjust the position of their penis in their underpants. They will also sometimes explore the interior of the foreskin with their fingers--a perfectly normal curiosity and nothing to worry about. It is important for parents to cultivate an enlightened and tender congeniality about such matters, otherwise they risk transferring unhealthy attitudes to their children.

Sometimes a boy will pull on his foreskin because it itches. All parts of the body itch occasionally. Even a circumcised boy has to scratch his penis. Just as you don't worry every time your child scratches his knee, so you should not worry when he scratches his penis. If the itch is caused by dry skin, then have your son avoid using soap on his penis. Treat the foreskin just as you would any other part of the body.

If the real fear is of masturbation, calmly remind yourself of the simple, natural fact that all children will explore their bodies, including their genitals. Touching their genitals gives children a pleasant feeling and relaxes them. Classic anatomical studies demonstrate that the foreskin is the most pleasurably sensitive part of the penis. You can congratulate yourself for having protected your child from a surgical amputation that would have permanently denied him normal sensations.

-Your son's foreskin is too long. It should be cut off.

There is tremendous variation in foreskin length. In some boys, the foreskin represents over half the length of the penis. In others, it barely reaches the end of the glans. All variations are normal. The foreskin is never "just extra skin" or "redundant." It is all there for a reason.

-Your child should be circumcised now because it will hurt more if it has to be done later, or worse, when he is an adult.

This excuse is tragically wrong and has resulted in a very serious crisis in American medical practice. It's based on the false idea that infants and young children don't feel pain. Babies can see, hear, taste, smell, and feel. In fact, babies feel pain more acutely than adults, and the younger the baby, the more acutely the pain is felt. If an adult needed to be circumcised, he would be given anesthesia and postoperative pain relief. Doctors almost never give babies either of these. The only reason doctors get away with circumcising babies without anesthesia is because the baby is defenseless and cannot protect himself. His screams of pain, terror, and agony are ignored. In any event, this all too common excuse is merely a scare tactic, one with tragic consequences for any baby forced to endure a surgical amputation without the benefit of anesthesia.

-Since your son is having anesthesia for another operation, we'll just go ahead and circumcise him.

Most parents are never told that their son is in danger of being circumcised during a tonsillectomy or surgery for a hernia or an undescended testicle. It would never occur to them. If your child is going into the hospital for any reason, be certain that you tell the physician, surgeon, and nurse that under no circumstances is your child to be circumcised. Write "No Circumcision" on the consent form, too. Then if your child is circumcised against your wishes, remember that you do have legal recourse.

-Your son has cysts under his foreskin. He needs to be circumcised.

During the period when the foreskin is undergoing the slow process of detaching itself from the glans, sloughed skin cells (smegma) may collect into small pockets of white "pearls." These are not cysts. Some doctors mistakenly think that the smegma under the foreskin is an infection, even though it is white rather than red, is cold to the touch, and is painless. As the foreskin proceeds with detachment, the body will do its job, and these pearls will pass out of the foreskin all by themselves. These collected pockets of cells are nothing to worry about. They are simply an indication that the natural process of detachment is occurring.

-Your son has a urinary tract infection (UTI) and needs to be circumcised to prevent it from happening again.

The belief that the foreskin slightly increases the chances of a boy having a UTI is highly controversial and, more importantly, unproven. Members of the medical profession in Europe do not accept it. Medical research proves that UTIs are most often caused by internal congenital deformities of the urinary tract. 2,3,4 The foreskin has nothing to do with this. Even if it could be proven that circumcision slightly reduces the risk of UTI, it is an absurd proposal because UTIs in boys are extremely rare and are easily treated with antibiotics. Breastfeeding, too, helps prevent UTIs. Child-friendly doctors advocate breastfeeding not penile surgery.

-Your son sprays when he urinates. Circumcision will correct this.

In almost every intact boy, the urine stream flows out of the urinary opening in the glans and through the foreskin in a neat stream. During the process of penile growth and development, some boys go through a period where the urine stream is diffused. Undoubtedly, many of these boys take great delight in this phase, while mothers, understandably, find it less amusing. If your boy has entered a spraying phase, simply instruct him to retract his foreskin enough to expose the meatus when he urinates. He will soon outgrow this phase.

-Your son's foreskin balloons when he urinates. He needs to be circumcised or else he will suffer kidney damage.

Ballooning of the foreskin during urination is a normal and temporary condition in some boys. It results in no discomfort and is usually a source of great delight for little boys. Ballooning comes as a surprise only to those adults who have no experience with this phase of penile development. It certainly does not cause kidney damage; it has nothing to do with the kidneys. Ballooning disappears as the foreskin and glans separate and the opening of the foreskin increases in diameter. It requires no treatment.

-Your son caught his foreskin in the zipper of his trousers; we will have to cut it off.

There have been rare cases where a boy has accidentally caught part of the skin of his penis in the zipper of his trousers. This is painful and can cause a lot of bleeding. Cutting off the foreskin, however, is illogical in this situation. By cutting across the bottom of the zipper with scissors, the zipper can easily be opened to release the penile tissue. Any lacerations in the skin can then be closed with either sutures or surgical tape, depending on the situation. The proper standard of care in this situation is to minimize and repair the injury, not make it worse by cutting off the foreskin and creating a larger and more painful surgical wound.

-Your son has phimosis. He needs to be circumcised to correct this problem.

Phimosis is often used as a diagnosis when a doctor does not understand that the child's foreskin is supposed to be long, narrow, attached to the glans, and resistant to retraction. Some doctors are prescribing steroid creams for phimosis, but this is unnecessary in children, since the foreskin does not need to be retractable in young boys. The hormones of puberty will do the same thing at the appropriate time that a steroid cream is doing prematurely. In adults who still have a foreskin that is attached to the glans or a foreskin with such a narrow opening that the glans cannot easily pass through it, steroid creams are a conservative therapy. This is if the adult wants a foreskin that fully retracts. Many males don't, preferring a foreskin that remains securely over the glans. It is purely a matter of personal choice, one that only each male can decide for himself.

-Your son has paraphimosis and must be circumcised to prevent it from happening again.

Paraphimosis is a rare dislocation of the foreskin. It is caused by the foreskin being prematurely retracted and becoming stuck behind the glans. The dislocation can most often be corrected by applying firm but gentle pressure on the glans with the thumbs, as if you were pushing a cork into a bottle. To reduce the swelling, an injection of hyaluronidase may be effective. Doctors in Britain have also reported good results from packing the penis in granulated sugar.5 Ice packs work well, too.

-Your son has BXO and will have to be circumcised.

Some doctors equate phimosis with an extremely rare skin disorder called balanitis xerotica obliterans (BXO), which is also called lichen sclerosus et atrophicus (LSA). BXO can appear anywhere on the body, but if this disorder affects the foreskin, it may turn the opening of the foreskin hard, white, sclerotic, and make retraction almost impossible. BXO is usually painless and progresses very slowly. Many times, it goes away by itself. To an experienced dermatologist, there is no mistaking BXO, but a diagnosis must be confirmed by a biopsy. The good news is that BXO can almost always be successfully cured with steroid creams, carbon dioxide laser treatment, or even antibiotics. Circumcision should be considered only after every other treatment option has failed. Just as we do not amputate the labia of females with BXO or the glans of circumcised boys with BXO, it is logical that we should not amputate the foreskin of intact boys with BXO.

-Your son needs to be circumcised or else he won't enjoy oral sex as an adult.

I'm afraid that doctors really have said such inappropriate things to parents. Such a statement is evidence of ignorance of the normal functions and sensations of the intact penis. Classic anatomical investigations have proven that the foreskin is the most richly innervated part of the penis. It has specialized nerve receptors that are directly connected to the pleasure centers of the brain. Your intact son is far better equipped to enjoy all aspects of lovemaking than his circumcised peers. The myth that American women prefer the circumcised penis is, in my opinion, demeaning to women. It may be true that American women of a certain generation and social background were more likely to be familiar with the circumcised penis than the intact penis, but this was the result of the mass circumcision campaigns of the 1950s not personal preference. I suspect that what women prefer in men is more related to the personal qualities of consideration, gentleness, sensitivity, warmth, and supportiveness. It is very unlikely that circumcision increases a male's capacity to develop these qualities.

-Your son needs to be circumcised so that he looks like his father.

A child is a mixture of both his mother's and his father's genetic heritage. He doesn't need to look like his father, nor will he ever look like his father in every way. Each child is a unique gift, and that uniqueness should be cherished. The idea that a boy will be disturbed if his penis does not look like his father's was invented to manipulate people into letting doctors circumcise their children. It has no basis in medical fact.

There are no published reports of an intact boy being disturbed because part of his penis was not cut off when he realized that part of his father's penis had been cut off. When intact boys with circumcised fathers express their feelings on the matter, they consistently report their immense relief and gratitude that they were spared penile surgery. They express sadness, as well, for the suffering their dads experienced as infants.6

Occasionally, a circumcised father will state that he wants his child circumcised because he thinks that it will create a bond between him and his son. It is a wonderful thing for a father to want to establish such a bond, but circumcision cannot accomplish this worthy goal. If a father wants to establish a lasting and meaningful bond with his son, the very best way, and perhaps the only way, he can achieve this is by spending quality time with him and by showing him much affection.

Sadly, some fathers who have been circumcised have an unhealthy attitude and may look for any excuse to schedule the child for circumcision. Putting a child in a position where he fears that part of his penis is going to be cut off is abusive. When fathers demand that their sons be circumcised, I suspect that they are desperately trying to justify their own circumcised condition. The emotions that some fathers feel when they are forced to confront the fact that part of their own penis is missing can be so disturbing that they will do anything to block them out.

A father who forcibly circumcises his son will not win his son's gratitude, affection, trust, or love. I am aware of instances where such events have permanently destroyed the father-son bond and changed a son's love for his father into rage and bitter resentment. In situations where the father suffers from an unhealthy attitude about his son's normal penis, I think it is best for everyone concerned--especially the son--for the father to receive compassionate psychological counseling to help him overcome his problem. All children deserve the saf est, most nurturing, and most loving home possible.

When physicians realize the important functions of the foreskin, they'll realize that just about every problem with it can and should be solved without cutting it off. Cutting off part of the body--especially part of the penis--is an extreme measure that should be reserved for the most extreme of circumstances. The only legitimate indications for cutting off any part of the body, including the foreskin, are life-threatening disease, life-threatening deformity, or irreparable damage. These situations are extremely rare.

The best advice for the care of the intact penis is simply to leave it alone. The intact penis needs no special care. Let your boy take care of it himself, and when he's old enough, he will enjoy taking care of his own body. After all, it's his business. Just relax and avoid worrying about your son's intact penis. Remind yourself that the foreskin is a normal and natural part of the body. If European boys grow up healthy and unconcerned with their foreskins, so can your son.

Organizations
If your physician or healthcare provider ever recommends that your child be circumcised, get another opinion from a physician who understands the important functions of the foreskin, no matter how "urgent" the situation may be. For help finding one in your area, contact:

Paul M. Fleiss, MD, MPH, is assistant clinical professor of pediatrics at the University of Southern California Medical Center and is in private pediatric practice in Los Angeles, California. He is the author of numerous scientific articles published in leading national and international medical journals.